GW1-2022-08564_Well Construction - GW1_20220527

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES '44 WATER` ONES ..-rs.. � . .r.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. ft.
NC Well Contractor Certification Number 45"OUTER CASING'formiilti-cased wells OR LINER ifa licable '
GEOLOGIC EXP LO RATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 ft. 168.0 ft- 6.0 SCH 40 PVC
16:INNERGASINGOR`TIIBING" eotheririalclosed-loo' :�
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS .MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:'GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOONT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK if a" Gc itilr a-
❑AquifeI Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer �a20.<DRILLING'I OG attac additibnal sheets'if ieceiii -
❑Geothermal(Heating/Cooling Return) 190ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
0.0 ft- 20.0 ft- RED CLAY
4.Date Well(s)Completed: 03/30/22 Well ID# OW-7D 20.0 ft- 50.0 ft- BROWN SILTY PWR
5a.Well Location: 50.0 it. 61.0 ft' WEATHERED ROCK
PIEDMONT LITHIUM 61.0 ft- 500.0 It- ROCK
Facility/Owner Name Facility ID#(if applicable) R. ft.
231 HASTINGS ROAD BESSEMER CITY 28016 ft. ft.
Physical Address,City,and Zip ft. M
GASTO N 21 REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-68.0-500.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "`*OBSERVATION'
(if well field,one lat(long is sufficient) 22.Certification:
350 22' 40.61" N 810 16' 56.74" W 05/19/22
6.Is(are)the well(s): I flPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the rvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction St dards and that a copy
Ifthis is a repair,fill out known ivell construction information and explain the nature ofthe ofthis record has been provided to the well owner. 16,1tJ1
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additi nal swell°construction info
c For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach Avditi�nat' l esif ne2essary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: 500. (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple ivells list all depths ifdilferent(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 12.0/6.0/7.875 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018